Provider Demographics
NPI:1043227515
Name:BENIAK, THOMAS EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:BENIAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5775 WAYZATA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1227
Mailing Address - Country:US
Mailing Address - Phone:952-525-4511
Mailing Address - Fax:952-525-1560
Practice Address - Street 1:5775 WAYZATA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-1227
Practice Address - Country:US
Practice Address - Phone:952-525-4511
Practice Address - Fax:952-525-1560
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0706103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP37238OtherHEALTHPARTNERS
765445OtherAMERICAS PPO
15-82098OtherMEDICA
01014969OtherPREFERRED ONE
ND10088Medicaid
71318BEOtherBLUE CROSS BLUE SHIELD
A015OtherTRIWEST
15-82098OtherMEDICA